Florida Medicaid. Prosthetic and Orthotic Durable Medical Equipment and Medical Supply Services Coverage Policy. Agency for Health Care Administration

Transcription

1 Florida Medicaid Prosthetic and Orthotic Durable Medical Equipment and Medical Supply Services Coverage Policy Agency for Health Care Administration

2 Table of Contents 1.0 Introduction Florida Medicaid Policies Statewide Medicaid Managed Care Plans Legal Authority Definitions Eligible Recipient General Criteria Who Can Receive Coinsurance and Copayments Eligible Provider General Criteria Who Can Provide Coverage Information... 2 General Criteria... 2 Specific Criteria... 2 Early and Periodic Screening, Diagnosis, and Treatment Exclusion General Non-Covered Criteria Specific Non-Covered Criteria Documentation General Criteria Specific Criteria Authorization General Criteria Specific Criteria Reimbursement General Criteria Claim Type Billing Code, Modifier, and Billing Unit Diagnosis Code Rate... 4 Draft Rule i

3 1.0 Introduction Florida Medicaid prosthetic and orthotic durable medical equipment and medical supply (DME) services provide custom and specialized equipment or orthotic devices to recipients with disabling conditions to sustain the recipient at home or in the community. 1.1 Florida Medicaid Policies This policy is intended for use by providers that render prosthetic and orthotic DME services to eligible Florida Medicaid recipients. It must be used in conjunction with Florida Medicaid s General Policies (as defined in section 1.3) and any applicable service-specific and claim reimbursement policies with which providers must comply. Note: All Florida Medicaid policies are promulgated in Rule Division 59G, Florida Administrative Code (F.A.C.). Coverage policies are available on the Agency for Health Care Administration s (AHCA) Web site at Statewide Medicaid Managed Care Plans Florida Medicaid managed care plans must comply with the service coverage requirements outlined in this policy, unless otherwise specified in the AHCA contract with the Florida Medicaid managed care plan. The provision of services to recipients enrolled in a Florida Medicaid managed care plan must not be subject to more stringent service coverage limits than specified in Florida Medicaid policies. 1.3 Legal Authority Florida Medicaid DME services are authorized by the following: Title XIX of the Social Security Act (SSA) Title 42, Code of Federal Regulations (CFR) Section , Florida Statutes (F.S.) 1.4 Definitions The following definitions are applicable to this policy. For additional definitions that are applicable to all sections of Rule Division 59G, F.A.C., please refer to Florida Medicaid s Definitions Policy Claim Reimbursement Policy A policy document found in Rule Division 59G, F.A.C. that provides instructions on how to bill for services Coverage and Limitations Handbook or Coverage Policy A policy document found in Rule Division 59G, F.A.C. that contains coverage information about a Florida Medicaid service General Policies A collective term for Florida Medicaid policy documents found in Rule Chapter 59G-1, F.A.C. containing information that applies to all providers (unless otherwise specified) rendering services to recipients Medically Necessary/Medical Necessity As defined in Rule 59G-1.010, F.A.C Provider The term used to describe any entity, facility, person, or group enrolled with AHCA to furnish services under the Florida Medicaid program in accordance with the provider agreement Recipient For the purpose of this coverage policy, the term used to describe an individual enrolled in Florida Medicaid (including managed care plan enrollees). Revised Date: Draft Rule 1

4 2.0 Eligible Recipient 2.1 General Criteria An eligible recipient must be enrolled in the Florida Medicaid program on the date of service and meet the criteria provided in this policy. Provider(s) must verify each recipient s eligibility each time a service is rendered. 2.2 Who Can Receive Florida Medicaid recipients requiring medically necessary prosthetic and orthotic DME services. Some services may be subject to additional coverage criteria as specified in section Coinsurance and Copayments There is no coinsurance or copayment for this service in accordance with section , F.S. For more information on copayment and coinsurance requirements and exemptions, please refer to Florida Medicaid s Copayments and Coinsurance Policy. 3.0 Eligible Provider 3.1 General Criteria Providers must meet the qualifications specified in this policy in order to be reimbursed for Florida Medicaid prosthetic and orthotic DME services. 3.2 Who Can Provide Services must be rendered by one of the following: Durable medical equipment and supply services businesses fully licensed in accordance with Chapter 400, F.S. Orthopedic physicians groups, primarily owned by physicians fully licensed in accordance with Chapter 468, F.S. Pharmacies fully licensed in accordance with Chapter 465, F.S. 4.0 Coverage Information General Criteria Florida Medicaid covers services that meet all of the following: Are determined medically necessary Do not duplicate another service Meet the criteria as specified in this policy Specific Criteria Florida Medicaid covers the following services in accordance with the American Medical Association s Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS), and the applicable Florida Medicaid fee schedule(s), or as specified in this policy: Breast prostheses Custom and specialized equipment when a less costly alternative is not available to fulfill the recipient s need Diabetic shoes and modifications Equipment maintenance and repair Orthotic devices for recipients that meet one of the following: Require support or correction of a weak or deformed body part Require restriction or elimination of motion in a diseased or injured body part Prosthetic devices for recipients that meet one of the following: Require replacement of all or part of a permanently inoperative body part Revised Date: Draft Rule 2

5 Require replacement of all or part of a missing body part Prosthetic eyes 5.0 Exclusion Early and Periodic Screening, Diagnosis, and Treatment As required by federal law, Florida Medicaid provides services to eligible recipients under the age of 21 years, if such services are medically necessary to correct or ameliorate a defect, a condition, or a physical or mental illness. Included are diagnostic services, treatment, equipment, supplies, and other measures described in section 1905(a) of the SSA, codified in Title 42 of the United States Code 1396d(a). As such, services for recipients under the age of 21 years exceeding the coverage described within this policy or the associated fee schedule may be approved, if medically necessary. For more information, please refer to Florida Medicaid s Authorization Requirements Policy. 5.1 General Non-Covered Criteria Services related to this policy are not covered when any of the following apply: The service does not meet the medical necessity criteria listed in section 1.0 The recipient does not meet the eligibility requirements listed in section 2.0 The service unnecessarily duplicates another provider s service 5.2 Specific Non-Covered Criteria Florida Medicaid does not cover the following as part of this service benefit: 6.0 Documentation Items included in a procedure code s description that are billed separately Non-prescription shoe inserts Personal comfort, convenience, hygiene, or sanitation items Repairs, replacement, and maintenance of any equipment in cases of misuse, abuse, neglect, loss, or wrongful disposition of equipment by a recipient, a recipient s legal representative, responsible caregiver, or provider Replacement parts, repairs, or labor for equipment within the warranty period Shipping, handling, labor, measuring, fitting, or adjusting separately Travel time and repair assessment time 6.1 General Criteria For information on general documentation requirements, please refer to Florida Medicaid s Recordkeeping and Documentation Policy. 6.2 Specific Criteria Providers must maintain one of the following in the recipient s file: Certificate of Medical Necessity that meets the following requirements: Specifies the type of DME prescribed Is less than 12 months old Is dated within 21 days after the initiation of service Current hospital discharge plan that clearly describes the type of DME item or service ordered Written prescription The documentation must be individualized and specify all of the following: Type of medical equipment Quantity Frequency of use Revised Date: Draft Rule 3

6 7.0 Authorization Length of time the recipient requires DME Providers must maintain the following documentation in the recipient s file, as applicable: Equipment and supply delivery, pick-up, and return documentation Recipient training documentation Rental equipment documentation Replacement of stolen or destroyed equipment documentation Used equipment documentation 7.1 General Criteria The authorization information described below is applicable to the fee-for-service delivery system. For more information on general authorization requirements, please refer to Florida Medicaid s Authorization Requirements Policy. 7.2 Specific Criteria Providers must obtain authorization from the quality improvement organization as follows: 8.0 Reimbursement When indicated on the applicable Florida Medicaid fee schedule(s) For non-classified procedure codes To exceed the coverage limits specified in section 4.0 for recipients age 21 years or older 8.1 General Criteria The reimbursement information below is applicable to the fee-for-service delivery system. 8.2 Claim Type Professional (837P/CMS-1500) 8.3 Billing Code, Modifier, and Billing Unit Providers must report the most current and appropriate billing code(s), modifier(s), and billing unit(s) for the service rendered, incorporated by reference in Rule 59G-4.002, F.A.C. Providers must include a non-classified procedure code for customized equipment on the claim form. 8.4 Diagnosis Code Providers must report the most current and appropriate diagnosis code to the highest level of specificity that supports medical necessity, as appropriate for this service. 8.5 Rate For a schedule of rates, incorporated by reference in Rule 59G-4.002, F.A.C., visit AHCA s Web site at By Report Claims Providers must submit medical necessity and product or service documentation to AHCA for pricing. Revised Date: Draft Rule 4